Approaching Clinical
Decision Making in Nursing Practice with Interactive Multimedia and Case-Based
Reasoning
Som Naidu, (s.naidu@meu.unimelb.edu.au)
The University of Melbourne
Mary Oliver, (oliver@usq.edu.au) The University of Southern Queensland
Andy Koronios, (koronios@usq.edu.au) The University of Southern Queensland
Abstract
This paper describes the
conceptual design, development and formative evaluation of a self-paced multimedia
learning resource that is intended to facilitate clinical decision making in
nursing practice with case-based reasoning. With the help of a contrived situation,
the resource attempts to simulate the complexities of life in a typical hospital
ward, which places graduating nurses in the role of problem-solvers. Problem
solving in the simulation is based on a rich repertoire of cases and stories
that have been extracted from the experiences of expert practitioners. This
case-based reasoning architecture reflects a model of learning where graduating
nurses are coached in the development of decision-making skills within the context
of a contrived but an authentic problem. Formative evaluation of this multimedia
resource using structured and open-ended question types has been carried out
with individual and small groups of practicing nurses. Their general impressions
of this resource, and especially its approach to learning, have been positive.
More extensive evaluation of the resource is currently in progress.
1. Educational Problem
In much of Australia
(and very likely elsewhere), approaches to the preparation of nursing students
for a successful transition into the workplace has been found to be ineffective.
Recognizing that more of the same kind of support was not going to be useful,
we argued for a radical shift in helping graduating nurses to make the transition
into the workplace. Our proposition combines powerful educational technologies
and proven learning strategies to build a self-paced technology-enhanced learning
environment. Governments, health care organisations and nurse educators have
also suggested that in order to prepare better nursing graduates for the challenges
of the workplace, there must be alternative ways of preparing graduating nurses
for the demands of clinical decision making in situ. An obvious improvement
would be increased collaboration between the employing organizations and nursing
education institutions to provide realistic learning situations outside the
formal classroom, and offered in a self-paced and self-instructional environment.
These alternative learning opportunities would need to be solidly grounded in
the authentic problems and situations of the nurses’ daily routines. The learning
tasks would need to be immediately relevant and meaningful to them, and not
too removed from their workplace environment.
Our pedagogy is based on the belief that learning is most efficient and effective when it is situated in realistic settings where learners are clear, not only about the reasons for learning but the context or the ecology of their learning environment. This view contrasts with the notion that subject matter can be represented in schemas stored in memory and retrieved when needed. Gestalt psychologists, such as Wertheimer, Kohler, and Koffka, argued in favour of the role of insight, perception and reflection in the learning process as opposed to association based primarily on past experience, such as that proposed by Thorndike, Skinner and Pavlov (Bower and Hilgard, 1981). Because we wanted to create situations that were not only motivating and challenging, but that necessitated learning of facts, principles and procedures, we used a Goal-Based Scenario (Schank, 1997). A Goal-Based Scenario (GBS) is essentially a simulation in which learners assume a main role. Their "goal" is to accomplish the mission or task associated with their main role in the scenario. In order to achieve this goal the learner needs to acquire particular skills and knowledge. This is where the learning is taking place. Goals in this context refer to the successful completion of the task at hand, not the achievement of grades. A GBS serves both, to motivate learners and also give them the opportunity to "learn by doing." As long as a goal is of inherent interest to learners, and the skills needed to accomplish those goals are the targeted learning outcomes, we have a match and a workable GBS. The important idea here is that a GBS is organized around "performance" skills and the result is a student who can perform the specified task.
3. Design ArchitectureIn this multimedia learning environment case-based reasoning is used to improve current instructional practices in the education of nurses for their transition into the workplace. (See Figure 1.) The intent of this model is to present students with a contrived but an authentic scenario, which offers them an opportunity to learn in a safe environment, and by making mistakes without injury to real human patients. We argue that mistakes offer real opportunities for learning when these are accompanied by timely and potent feedback. We will now describe this model in some detail.
Clinical Decision Making with Case-Based Reasoning |
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Phase I: Case Encounter
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Phase II: Understanding Problem |
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Precipitating event |
Identifying its causes |
Managing the crisis |
Learner encounters the precipitating event. |
Learner seeks to locate the causes of the precipitating event. |
Learner attempts to deal with the crisis and contain it. |
Phase II: Seeking Solutions |
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Making decisions |
Listening to Stories |
Case-Based Reasoning |
Learners are required to make decisions about patient care. |
They listen to experts and ask questions about their experiences. |
Learners attempt to reason on the basis of the experts' stories. |
Phase III: At the Case Conference |
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Raising issues |
Listening to Stories |
Developing Care Plan |
Learners explore new and related issues to the problem by reviewing sources of information. |
They ask experts additional questions about their experiences. |
Learners develop their final care plan based on experts' stories. |
Phase IV: Developing a Care Plan |
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Figure 1. Clinical decision making in nursing practice with case-based reasoning. The phases in the model guide users through procedures for using the repository of cases.
3.1 The Goal
As users enter this learning environment a short welcoming video clip explains
its context and their "goal" within it. The "goal" for the learner in this simulation
is to deal with the crisis situation and develop an action plan for managing
the patient's care. This "goal" is not the same as a learning outcome but a
means to achieving one or more learning outcomes.
Demo
1. A real G2 streaming movie showing the guide outlining
the goal
3.2 Case Encounter
Following statement of the goal, users proceed to the handover. This
is a routine event in nursing practice, where nurses coming on for duty are
brought up-to-date by their outgoing colleagues on the condition of patients
who are in their care. In this simulation this occurs at a small meeting in
the presence of the medical practitioner as well as other staff. At this meeting
the outgoing nurse outlines the background on one of the patients (Mr. George
Parker) around which this simulation is built.
Demo 2. A real G2 streaming
movie showing the video clip of handover
3.3 User Actions
After handover, nurses would usually begin their work. At this point
in the simulation, a number of options are available to users. They may go to
the nurses' station, review their goal, watch the handover video clip,
study learning outcomes of the presentation, take notes on the handover,
or examine the questions and issues they ought to be considering for preparing
their care plan. Throughout the simulation, users can view two versions of each
video clip; one displays the entire procedure or event and another is annotated
with subtitles to highlight, to the learner, the salient points of a particular
procedure or event. If at any time, the user is unsure of what to do, the "now
what" facility will offer advice on possible actions. These are a series of
short video clips that give general advice on meaningful actions users can take.
However, these do not offer specific help to the users, as there is none.
Demo 3. A real G2
streaming sound clip showing an example "Now What" advice
3.4 Taking Notes
This facility enables users to take notes as they work through the simulation.
At the moment, this is a simple text editor, which allows for only text input.
This is not a very structured facility although it could be made into one, depending
on the kind of cognitive support we feel users in this environment need in order
to prepare their patient care plan. It could be improved to allow for the accumulation
and organisation of other data types such as images, audio and video clips etc.
which would enable users to develop resourceful and more detailed care plans
as they go along.
Figure 2. An example of the notebook.
3.5 Administering Antibiotics
As in a real hospital setting, after handover nurses move on to attend
to routine nursing care activities and meeting patients' needs by administering
medications and ensuring patients' comfort. In this instance, the two nurses
in the simulation proceed to administer antibiotics to the patient in the simulation,
Mr. George Parker. While this comprises a very routine event, there are a number
of valuable lessons that are being learned by the novice nurse practitioner.
These lessons have to do with the appropriate procedures for administering medication,
such as reviewing patient notes, policies, procedures and protocols, checking
equipment, and also consulting expert practitioners.
Demo 4. A real G2 streaming
movie showing the video clip of administration of antibiotics
3.6 Precipitating
Event
Following the administration of antibiotics on Mr. George Parker, users are
met with a "precipitating event". A precipitating event in this instance is
an emergency situation that causes, or has the potential to cause, a chain of
events. It requires the nurse to make complex decisions under the pressure of
time. Within this learning environment, however, time is not a variable because
this is a contrived learning situation in which users have the opportunity to
review relevant documentation and seek advice from experts, if necessary, on
the best practice before making decisions. As such, this comprises a "safe"
learning environment for users where they can make mistakes with impunity. Being
able to learn from one's mistakes is an important point that is being made here.
This is possible in this learning environment but obviously not possible in
real life situations.
Demo 5. A real G2
streaming movie showing the video clip of George Parker experiencing anaphylaxis
3.7 Managing the Situation
In the first instance, the nurse must do everything that is necessary to manage
the crisis situation before recommending a care plan. In order to do this, it
is necessary to first understand the crisis situation, including its
causes. In this scenario Mr. George Parker (patient) is experiencing an anaphylactic
reaction to the antibiotics he was administered earlier. To diagnose this situation
accurately, the learner needs to assess the patient's condition. In order to
arrive at a correct diagnosis, the novice nurse practitioner can access a whole
range of information including documentation on hospital procedures/protocols,
stories by expert practitioners (experienced nurses) which also comprise advice
on appropriate procedures to follow or not to follow under such circumstances.
Demo 6. A real G2
streaming movie showing the video clip of the two nurses attending to George
Parker
3.8 Learning Transcation
Following this diagnosis, nurse practitioners must take appropriate action to
manage the crisis situation. But before this is possible, they are prompted
by the simulation to identify and sequence (from lists) appropriate actions
that are necessary for correct diagnosis and management of the anaphylactic
reaction. For example, during diagnosis the system asks the learner, "What
would you be looking for to confirm that George Parker is at risk of an anaphylactic
reaction?" It allows users to choose from a list of past events
or patient characteristics the appropriate triggers that would confirm that
this patient is, indeed, at risk of an anaphylactic reaction. This learning
transaction requires learners to make decisions about prioritising and delivering
appropriate care.
Figure 3. An example
the drag and drop activity
A number of resources are available to users at this point to enable them to make informed decisions about what are the appropriate actions to take in situations like this. These comprise electronic resources on anaphylaxis including intervention strategies and case studies of anaphylaxis.
Figure
4. An example Internet access site
However, the most important
resource that users have access to in this learning environment is the stories
of experienced nurse practitioners. Users are able to make informed decisions
after having listened to the experiences of expert practitioners. These stories
represent the "strategic" (also known as the experiential) knowledge of expert
practitioners. This kind of knowledge comes only with experience over many years,
and is not normally available in textbooks. Most computer-based (including on-line)
learning environments fail to bring good stories to the student. They tend to
concentrate too much on "declarative" content (ie., facts, procedures and principles),
but they fail to recognise that people learn most effectively from the experiences
of expert practitioners. This learning environment relies on using cases and
stories, and experiences of expert practitioners to enable novice practitioners
to make appropriate and informed decisions. This is where the learning takes
place.
Demo 7. A real G2
streaming movie showing the video clip of a powerful story
3.9 Reflecting at
Case Conference
When a care plan has been developed, users proceed to a case conference. This
is a place where users have the opportunity to reflect upon their own care plans
and that of others. They have the opportunity here to engage in collaborative
questioning, critiquing, negotiation of meanings, and commenting on alternative
approaches of care that are deemed appropriate to the case. This can invoke
cognitive conflict in the learner, which has the potential to lead to changing
perceptions that result in learning.
Demo 8. A real G2
streaming movie showing the video clip of case conference
3.10 Developing a
Care Plan
By now, novice practitioners are in a position to develop a care plan that is
based on informed decision making. It will have become clear to users that the
process of reaching this stage is more important than having the care plan accepted
by their supervisors. This process has been designed to develop in learners
clinical decision making skills, and it seeks to achieve that by urging users
to learn from the experiences of expert practitioners. Its expressed intent
is to expose nurses to the process of clinical decision making and encourage
them to make decisions on this basis so that this process becomes almost automatic
for them. Ultimately, within this "case-based reasoning" environment, users
are able to improve their problem solving skills and ability with making appropriate
clinical decisions concerning patient care.
4. Procedure
The first step in the development procedure for this project was to develop
and shoot the "precipitating event." The experiencing of anaphylaxis was chosen
as the event because it represents a reasonably complex occurrence in a hospital
as well as a common scenario in the community, for example, it may occur when
children receive immunisations at the clinic, or when someone has been stung
by a bug, etc. Except for the patient experiencing anaphylaxis, all other participants
in this video shoot were educators and health professionals. The next major
task was to capture a large enough repository of the experiences of nurse practitioners
in the form of stories. Gathering this repository was no mean task. Interviewing,
filming, and editing of these stories took up much time. Indexing of the database
of these stories was an ongoing exercise.
The model of learning outlined in Figure 1 guided the development of the learning transaction. This unfolded in several phases. Within the multimedia simulation, users could move easily from activity to activity towards their ultimate goal, which was the successful management of the presenting problem. Some of these activities comprised making selections from a number of decision options, dragging and dropping them in appropriate boxes, deciding to administer a particular treatment or not, deciding to call for help or not, choosing to consult expert video clips for advisement or not, and making decisions. Resources apart from expert's stories such as procedures and other reference manuals had to be identified and collected for the reference of users.
5. Development6. Evaluation
Our approach to the monitoring
and evaluation of the outcomes of this project is utilisation focussed. As such
our focus has been on the use and utility of the instructional innovation for
nursing students, their lecturers, graduate nurses, and other stakeholders such
as the employing institutions. Evaluation of the courseware prototype is continuing.
Formative evaluation of courseware has been carried out with small groups of
potential users including a small group (n=3) of subject matter experts
who were asked to validate, among other things, the authenticity of anaphylaxis.
A semi-structured Expert Group Checklist (see Appendix A) has been used for
gathering the comments of the expert group. A semi-structured questionnaire
including an Interface Rating Scale (see Appendix B) has been used to collect
data from the group of potential users. A larger scale implementation evaluation
of this courseware is planned. This will involve observations, focus groups
and use of semi-structured questionnaires.
Results of the formative evaluation carried out so far show that users find the learning program easy to use and navigate. The majority did not find the information overwhelming, and felt that the content was pitched at an appropriate level for the target group. With regards to interface design, users felt that the screen design was pleasing, appropriate use of graphics had been made, and that the clarity of information presentation was high. On the whole users surveyed found the program enjoyable. Subjects were asked how interesting they found the material on each one of the sections on the CD. Material on the CD was itemised to include: Handover, attending to patient, listening to stories, making decisions, and preparing the report. The majority found each one of these sections as either interesting or very interesting. Subjects were also asked to rate the usefulness to them of these same attributes. All of them rated these attributes either useful or very useful. In summary, what they liked most about this multimedia-based simulation included simple access to different components, more interesting information, better retention in comparison with reading a journal article or book, realistic presentation, and interactive patient observation.
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8. Acknowledgments
This project has been funded by The Committee for University Teaching and
Staff Development, The Federal Department of Education and Youth Affairs,
Australia.
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IMEJ multimedia team member assigned to this paper